Monday, November 12, 2007

Overweight men with prostate cancer have a higher risk of dying

Men who are overweight when they have locally advanced prostate cancer have almost double the risk of dying from the disease compared with men of normal weight, new research says.

The study, led by a team at Massachusetts General Hospital, is the first to find that excess weight alone is associated with deaths in men whose tumors had grown beyond the prostate or spread to lymph nodes, according to the study, which appears in the journal Cancer.

"The prevalence of overweight and obesity continues to increase in United States, so it’s an issue that's perhaps more important than ever," author Dr. Matthew R. Smith said in an interview. "What we need to do from here are additional studies to understand the mechanisms by which overweight and obesity are associated with worse prostate cancer mortality."

For men with a normal body mass index of 25, the death rate from prostate cancer was 6.5 percent after eight years. For overweight men, with a BMI between 25 and 30, it was 13.1 percent, and for obese men, with a BMI over 30, the death rate was 12.2 percent.

Obesity is not a new suspect in prostate cancer. Previous work has linked being overweight to having more aggressive forms of the cancer and higher rates of recurrence after radiation and surgery to remove the prostate gland. But other potential reasons for the difference in outcomes, from difficulty examining obese patients to possible biases in screenings, had not been isolated in the observational studies.

The study reported in Cancer analyzed data from a large randomized trial originally conducted to study radiation and hormone therapy in about 900 men with prostate cancer. That means the men had similar disease characteristics to be included in the trial. The authors, who also include researchers from Fox Chase Cancer Center and UCLA, looked at the men's BMI at the start of the trial and what happened to them over about eight years of follow-up.

Dr. Oliver Sartor of Dana-Farber Cancer Institute said the researchers have made an important observation from a well-designed trial.

"Now the hypothesis-driven question to ask is whether or not weight loss after diagnosis with prostate cancer will lead to better outcomes," he said in an interview. "That's an important question."

Posted by Elizabeth Cooney at 07:00 AM

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Tuesday, November 6, 2007

Two Brigham surgeons top list of device maker payments

By Elizabeth Cooney, Globe Correspondent

Two Boston orthopedic surgeons each received $6.75 million this year from a maker of joint replacement implants, the largest among hundreds of payments revealed in a $311 million settlement of a federal criminal case that alleged five companies paid doctors to use their products.

Dr. Richard Scott and Dr. Thomas Thornhill of Brigham and Women's Hospital were paid royalties and consulting fees this year by the Johnson & Johnson subsidiary DePuy Orthopaedics, according to documents made public by the company last week. DePuy makes implants used in hip and knee replacements.

Four other companies -- Zimmer Inc., Biomet Orthopedics Inc., Smith & Nephew Inc. and Stryker Orthopaedics -- were also part of an agreement with the US Department of Justice. The five companies, which together share 95 percent of the market for hip and knee implants, were being investigated for using consulting agreements with orthopedic surgeons to influence their choice of implants. Making payments was a common practice from 2002 through 2006, according to the US Attorney's Office in New Jersey.

The disclosures come as payments to doctors by device and drug companies come under increasing scrutiny because of concerns they create a financial conflict for physicians. But the industry, and many doctors and hospitals, defend the practice, saying it fosters innovation and properly rewards physicians for helping to develop new treatments.

Without admitting fault, the device companies agreed to make public their lists of payments for this year. Michael Drewniak, a spokesman for the US Attorney's Office, said in an interview yesterday that this year's payments were similar to amounts in previous years his office examined. More than 40 surgeons were paid $1 million or more this year, the lists showed.

Scott and Thornhill said in a statement supplied by Brigham and Women's that the royalties come from their design of a knee replacement implant licensed to J&J in 1986 and a hip replacement implant licensed in 1991. They said they donate their fees from consulting to charity.

"We are both very proud of the work we have done over the years to advance the mission of orthopedic medicine," their statement said.

Scott and Thornhill do not receive royalties when they or any other surgeons use their implants at the Brigham, they said. They did not break down the amounts of royalties and fees, nor were they available to comment beyond their statement.

DePuy, which will pay a fine of $84.7 million, issued a statement last week saying, "The surgeons who received the most significant compensation from DePuy Orthopaedics contributed intellectual property and ongoing expertise to the development of products."

Zimmer listed 15 Massachusetts General Hospital surgeons who received payments totaling $8.7 million this year. The hospital said in a statement that the money represents royalties for developing materials in the 1990s that are used in implants, and that the money goes to the hospital. Mass. General does not get royalties for implants that its surgeons use at the hospital.

"Ongoing research in orthopaedic surgery has led to enhancements in strength and durability of the materials, and the MGH continues to work with industry, including Zimmer and Biomet, to license and patent innovations that will benefit patients now and in the future," the hospital statement said.

Criminal complaints were filed against four of the five implant makers, charging them with conspiring to violate the federal anti-kickback statute, the US Attorney's office said, but the complaints will be dismissed if the companies comply with terms that include federal monitoring for 18 months and five-year corporate integrity agreements. Stryker cooperated with the investigation before the other companies and has entered a non-prosecution agreement with the government.

Zimmer will pay a fine of $169.5 million, Smith & Nephew will pay $28.9 million, and Biomet will pay $26.9 million.

Posted by Elizabeth Cooney at 06:18 PM

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Friday, November 2, 2007

Compassionate caregiver connects with patients and families

Barbara Moscowitz (left) thinks older adults are overlooked by people who can't see past their walkers and hearing aids, their illnesses and infirmities, to the human beings inside.

"I want to live in a universe that will see me not as a long list of chronic diseases but as an individual first who might have to cope with illness," Moscowitz, 54, said in an interview.

For her work at Massachusetts General Hospital with people with Alzheimer's and their families, she received the Kenneth B. Schwartz Center's Compassionate Caregiver of the Year Award last night at a dinner attended by 1,700 people. The honor is named for the Boston lawyer who, while being treated for the lung cancer he would die of, wrote movingly in the Boston Globe magazine about how his caregivers' human touch "made the unbearable bearable."

Coordinator of geriatric social work at Mass. General, Moscowitz focuses on the needs of families confronting their loved ones' diagnosis with Alzheimer's disease.

"So many families of Alzheimer's patients need so much support and guidance. It's like learning a new language," she said. "It just disturbs me greatly that a lot of people are given a diagnosis and then a web site or telephone number and told to go off and figure it out."

Moscowitz gave unwavering assistance to Kasey Kaufman when her mother was slipping away into the fog of dementia, the former CBS4 reporter said in a letter nominating Moscowitz for the Schwartz award.

"I like to say that Barbara saved our lives but that would be telling only part of the story," she wrote. "Barbara helped us to understand my mom's illness."

Kaufman's mother called Moscowitz "that tiny gal with the big heart," Kaufman's letter said.

Patricia Bresky, a psychologist in California, said in her first phone conversation with Moscowitz, she grasped not only her father's medical condition but also the family dynamics.

"For the first time since the onset of my father's symptoms two years before, I felt the ground beneath me," Bresky said in a letter to the Schwartz Center.

Moscowitz said she values the Schwartz Center's work to keep human connections alive in healthcare that can be hurried.

"They are the penicillin for what ails medicine now," she said.

Posted by Elizabeth Cooney at 09:18 AM

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Tuesday, October 30, 2007

Specialist referrals for imaging vary with who does the test, Mass. General study says

Doctors who send their patients for imaging tests to someone in their own specialty order diagnostic imaging more frequently than doctors who refer their patients to radiologists, Boston researchers report.

The reason for the difference may be financial, radiologist Dr. G. Scott Gazelle of Massachusetts General Hospital said in an interview about his article in the November issue of Radiology.

But that's impossible to know from the study's results, Dr. Nicholas DiNubile, a spokesman for the American Academy of Orthopedic Surgeons, responded in an interview, saying numbers of MRIs, CT scans, and X-rays alone can't determine whether they are ordered too often or not enough.

Looking at a national database of outpatient visits for such conditions as heart problems, broken bones, joint pain or suspected stroke, Gazelle and his team from the Institute for Technology Assessment at Mass. General found that physicians ordered imaging tests up to twice as often if they referred patients to doctors in their own specialty such as cardiology, orthopedics or neurology, compared with doctors who sent their patients to radiologists.

Previous research has indicated that doctors may order more scans when referring patients to a facility they own, but the authors of the new study decided to look at same-specialty referrals overall, rather than only referrals doctors made to imaging facilities they own. Gazelle said the authors made that choice in light of laws intended to curb self-referral that restrict some Medicare payments to doctors who refer patients to themselves.

"People are much more clever about it now," said Gazelle, who is on the board of chancellors of the American College of Radiology. "Same-specialty referral is in my view a proxy for self-referral."

All imaging has grown rapidly over recent years, but imaging done by non-radiologists has grown faster than imaging by radiologists, the study notes.

"I don't have a problem if a cardiologist or an orthopedist interprets imaging studies if they are qualified and do a good job," Gazelle said. "I do have a problem with the financial motivation to overuse it."

DiNubile, a knee specialist in Havertown, Penn., whose 25-surgeon group has its own imaging center staffed by a radiologist, said there is a turf war between specialists and radiologists who want to get back their business. He faults the study for not saying who owned the imaging facility where patients are being sent.

"The real question is whether that increases referrals when the physician owns his own shop," he said.

A better way to evaluate utilization rates would be to examine the imaging tests themselves to see if they were ordered appropriately, DiNubile said. Too many normal readings would suggest that too many tests are being ordered, for example.

"You always want to be sure to do the right thing," DiNubile said. "Is the right thing more utilization or less?"

Gazelle said the study was not intended to measure the quality of the imaging tests.

"The issue is we are using societal resources to pay for healthcare," he said. "We all ought to be ordering studies for the same reason."

Posted by Elizabeth Cooney at 01:39 PM

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Scientists rate Mass. General best place to work

Massachusetts General Hospital is the best place to work in academia, according to a survey of scientists by The Scientist. Beth Israel Deaconess Medical Center ranked 10th and Dana-Farber Cancer Institute came in 34th in the magazine's list of top 40 US academic institutions.

The poll asked respondents to rate their working environment. Mass. General scored high in job satisfaction, peers, management and policies, and infrastructure and environment, the magazine reports in its November issue, which will go online tomorrow.

The Top 15 institutions in the U.S.:

1. Massachusetts General Hospital, Boston, MA
2. National Cancer Institute-Frederick, Frederick, MD
3. Clemson University, Clemson, SC
4. Purdue University, West Lafayette, IN
5. Trudeau Institute, Saranac Lake, NY
6. St. Jude Children's Research Hospital, Memphis, TN
7. The J. David Gladstone Institutes, San Francisco, CA
8. University of Nebraska - Lincoln, NE
9. University of Texas Southwestern Medical Center, Dallas, TX
10. Beth Israel Deaconess Medical Center, Boston, MA
11. University of Texas M.D. Anderson Cancer Center, Houston, TX
12. Duke University, Durham, NC
13. Wadsworth Center, Albany, NY
14. Georgia Institute of Technology, Atlanta, GA
15. Mayo Clinic, Rochester, MN

Posted by Elizabeth Cooney at 10:36 AM

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Wednesday, October 24, 2007

Boston group to share genetic data on autism

A Boston group is sharing genetic information from families affected by autism with other researchers to promote understanding of the developmental disorder.

The Autism Consortium, whose members include hospitals, medical schools and universities in the Boston area, will transfer profiles of 500,000 genetic variations found across the genomes of 700 families with two or more children who have autism. The data will be held by the Autism Genetic Resource Exchange, a program of the advocacy organization Autism Speaks. Scientists can apply to the exchange, which gathered DNA from the families. The samples have been scanned for sequences where there are deletions or extra copies of DNA segments. The consortium is sharing the genetic variations it found.

"We returned all of the raw data to AGRE so they can distribute it to any other investigtors who want to begin exploring what may be the genetic underpinnings of autism," Mark Daly, a consortium member from Massachusetts General Hospital and the Broad Institute of MIT and Harvard, said in an interview. "Understanding the genetics underlying a complex disease is not an easy problem to solve. So there's no excuse for hoarding your data when much more can be learned by sharing."

Only a small percentage of autism arises from a recognizable genetic cause, such as Fragile X syndrome, Daly said. Recent research suggests that some families with autism might have higher rates of genomic abnormalities, but very few of these abnormalities have been conclusively identified.

"There's very strong heritability to autism but very little of the heritability has been explained by specific mutations of specific genes," he said. "What we hope is that this data is a starting point. We need to perform collaborative research in the spirit of the Human Genome Project to deliver on the trust the public has placed in us."

Members of the Autism Consortium are Beth Israel Deaconess Medical Center, Boston Medical Center, Boston University, Boston University School of Medicine, the Broad Institute of MIT and Harvard, Cambridge Health Alliance, Children’s Hospital Boston, Harvard University, Harvard Medical School, Massachusetts General Hospital, Massachusetts Institute of Technology, McLean Hospital and Tufts-New England Medical Center.

Posted by Elizabeth Cooney at 11:37 AM

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MGH to study fish oil compounds as treatment for depression

Two compounds in fish oil will be tested as treatments for depression by researchers in Boston and Los Angeles.

Massachusetts General Hospital in Boston and Cedars-Sinai Medical Center in Los Angeles are recruiting volunteers for a randomized clinical trial that will compare two omega-3 fatty acids, DHA and EPA, against each other and against inactive pills in 300 adults who have major depression, the hospitals said. To be eligible, participants must not be taking anti-depressant medications, principal investigator Dr. David Mischoulon of Mass. General said in an e-mail interview.

Previous studies have suggested that the fatty acids, which are found in salmon, mackerel and tuna, might help reverse depression by affecting brain processes involved in regulating mood. The compounds have not been systematically tested before.

In this five-year trial, participants and researchers will not know who is taking an omega-3 supplement and who is not. People will be enrolled in the trial for eight weeks, after which they will be eligible for three months of free follow-up care from a physician in the study.

To learn more about the study, which is funded by the National Institutes of Health, call Mass. General’s Depression Clinical and Research Program at (877) 552-5837 or Cedars-Sinai at (888) 233-2773.

Posted by Elizabeth Cooney at 11:28 AM

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Monday, October 22, 2007

Notables

David H. Koch, an MIT alum and prostate cancer survivor who earlier this month pledged $100 million to build a new cancer research center at MIT, will donate $5 million to the Prostate Cancer Foundation for an initiative using nanotechnology. Four research institutions will collaborate on ways to use the technique, in which tiny particles are designed to attack tumors but spare normal cells, according to the foundation. Dr. Omid Farokhzad of Brigham and Women's Hospital is the principal investigator, Robert Langer of MIT will lead engineering and manufacturing for the project, Dr. Philip Kantoff of the Dana-Farber/Harvard Cancer Center Prostate Cancer Program will head clinical research, and Dr. Neil Bander, an antibody expert, will direct a group from the Weill Cornell Medical College.

Dr. Jonathan Winickoff of the MassGeneral Hospital for Children has won a $4 million grant from the National Institutes of Health to conduct a trial to help protect children from second-hand smoke by encouraging their parents to quit smoking. The study is based on a pilot program that targeted parents in their children's pediatrician's office. Fifty pediatric practices are being recruited through the American Academy of Pediatrics' Pediatric Research in Office Settings network.

Dr. Jeffrey Flier, dean of Harvard Medical School, and Lita Nelsen, director of MIT's Technology Licensing Office, have been named 2007 Biomedical Research Leaders by the Massachusetts Society for Medical Research. Flier was honored for his commitment to diabetes and obesity research and medical education, according to the nonprofit society, whose members include universities, hospitals, research institutes, and biotech and pharmaceutical companies. Nelsen was recognized for managing 500 new inventions per year from MIT, the Whitehead Institute and Lincoln Laboratory.

Dr. Joseph Vacanti, chief of surgery at the MassGeneral Hospital for Children, has won the 2007 John Scott Award for his work in tissue engineering. Since 1834, the awards, administered by a board acting for the city of Philadelphia, have recognized inventions that contribute to mankind's "comfort, welfare and happiness," according to the board. Vacanti's work combines engineering and biology to develop substitutes to help tissue or organs function. He shares this year's prize with Dr. Albert J. Stunkard of the University of Pennsylvania School of Medicine, who is being honored for his work to understand and treat eating disorders.

Posted by Elizabeth Cooney at 05:50 PM

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Tuesday, October 16, 2007

Ties between industry and medical schools widespread, survey finds

Almost two-thirds of the people leading medical school departments have personal relationships with industry and two-thirds of these departments have similar ties, a survey of 140 medical schools and top-funded teaching hospitals found. Most of the doctors polled said their relationships had no effect on their decisions, but they thought multiple conflicts of others could lead to biased research.

"When you say 'everyone's doing it,' the accumulation of data suggests that's really true," Eric G. Campbell, associate professor of health policy at the Massachusetts General Hospital Institute for Health Policy, said in an interview. He is the lead author of the study appearing in tomorrow's Journal of the American Medical Association. "There is virtually no aspect of medical education in which drug companies don't have significant relationships."

Campbell said the study gives the first portrayal of the links between companies and medical schools on the department level. The authors sampled departments of medicine, psychiatry, microbiology and one other nonclinical department at each surveyed institution.

They asked the individual chairs if they had served on company boards or speakers bureaus, been a paid consultant, or received compensation in the form of stock options, travel subsidies or honoraria. For departments, the questions were whether they got unrestricted funds, support for graduate students, or money for holding research seminars. They were asked if discretionary funds from industry paid for food and beverage, travel to meetings, journal subscriptions, software, or research or clinical equipment.

When asked about other chairs' involvement with companies, almost three-quarters of the respondents thought having more than one substantial role, such as being a consultant and a board member, would harm the department's ability to conduct independent research.

"Failure to address the existence and influence of industry relationships with academic institutions could endanger the trust of the public in US medical schools and teaching hospitals," the authors concluded.

Posted by Elizabeth Cooney at 04:00 PM

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Thursday, October 11, 2007

Four Boston doctors named Howard Hughes investigators

From left, Daley, Engle, Haber and Karumanchi

Four Boston physician-scientists have been selected by the Howard Hughes Medical Institute in an initiative to promote patient-oriented research.

Dr. George Daley and Dr. Elizabeth Engle, both of Children’s Hospital Boston, Dr. Daniel Haber of Massachusetts General Hospital, and Dr. S. Ananth Karumanchi of Beth Israel Deaconess Medical Center are among 15 new HHMI Investigators. Boston has the most winners in this new group.

Daley is a world leader in hematopoetic and embryonic stem cell research; Engle has identified genetic factors behind disorders that limit patients’ control over their eye movements; Haber studies how individuals’ genetic mutations affect their response to cancer drugs; and Karumanchi has identified the soluble proteins produced by the placenta that can trigger pre-eclampsia in a pregnant mother.

HHMI received 242 applications from eligible candidates. The 15 selected physician-scientists from 13 institutions will receive a total

of about $150 million in their first five-year terms.

Posted by Elizabeth Cooney at 07:00 AM

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Tuesday, October 9, 2007

Breast-feeding medical student to take licensing test tomorrow

By Elizabeth Cooney, Globe Correspondent

A Harvard medical student who went to court to get extra time to pump breast milk during a licensing exam will start taking the test tomorrow.

Sophie Currier, who is breast-feeding her 5-month-old daughter, sued the National Board of Medical Examiners on Sept. 5 when it refused to give her more than the usual 45-minute break allowed to students taking the nine-hour exam. Since then the case has gone through seven rulings.

Today the Supreme Judicial Court denied a request from the board for an expedited review of the case after a state Appeals Court ruling on Friday cleared the way for Currier to have the extra time. The examination board had also asked for a single justice to hear an appeal, but the court did not rule on that petition, board spokeswoman Carol Thomson said in an interview.

"Sophie Currier is scheduled to take the test tomorrow and the following day," Thomson said. "The board certainly will comply with the court's requirements and she will take the test with extra time."

Currier, who must pass the test before beginning her residency at Massachusetts General Hospital, has been granted permission to take the test over two days because of her dyslexia and attention deficit hyperactivity disorder. She will get an hour of extra break time each day.

The 33-year-old Brookline resident had argued that it would be uncomfortable and possibly harmful to her health if she could pump breast milk only during standard breaks.

Currier was unavailable to comment today, her spokeswoman Alex Zaroulis said.

"Sophie is looking forward to taking the test tomorrow. She's focused, she's prepared," Zaroulis said. "This has all been about Sophie being able to take this test and be able to express milk while she takes the test in a humane and sanitary way."

One of her lawyers said she found it troubling that the organization responsible for licensing doctors continues to take such an "anti-female approach."

"We took this case pro bono because we believed strongly in the legal positions that were set forth regarding a nursing mother's right in the workplace and by extension, a nursing mother's right to be able to become a doctor and take the medical exam without being at risk for physical harm," said Lauren Stiller Rikleen, who worked on the case with Christine Smith Collins of the law firm Bowditch & Dewey.

Posted by Elizabeth Cooney at 06:45 PM

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Monday, October 8, 2007

Five Boston researchers named to Institute of Medicine

Five Boston researchers have been elected to membership in the Institute of Medicine, a prestigious group established by the National Academies of Science to analyze health issues and make recommendations on policy.

Among the 65 new US members, five are from Massachusetts (four from Harvard, one from MIT), three are from Connecticut (all from Yale) and one is from New Hampshire (Dartmouth). The current 1,538 active members chose new members from candidates nominated for achievement and commitment to service, the IOM said in its announcement of new members today.

The Massachusetts members are:

Dr. Emery N. Brown, professor of anesthesia, department of anesthesia and critical care, Massachusetts General Hospital; and professor of computational neuroscience, health sciences, and technology, Massachusetts Institute of Technology

Dr. William G. Kaelin Jr., investigator, Howard Hughes Medical Institute, and professor, Harvard Medical School, Dana-Farber Cancer Institute

Dr. David T. Scadden, professor of medicine and co-chair, department of stem cell and regenerative biology, and co-director, Harvard Stem Cell Institute; and director, Center for Regenerative Medicine, Massachusetts General Hospital

Jonathan G. Seidman, professor of genetics, Harvard Medical School

B. Katherine Swartz, professor of health economics and policy, department of health policy and management, Harvard School of Public Health

The three new members from Connecticut are:

Dr. Robert J. Alpern, dean, Yale University School of Medicine

Dr. Harlan M. Krumholz, professor of medicine and epidemiology and public health, and professor of internal medicine, Yale University School of Medicine

Dr. Mary E. Tinetti, professor of medicine, epidemiology and public health, and director, Yale Program on Aging, Yale University School of Medicine

New Hampshire has one new member:

Jonathan S. Skinner, professor of economics, Dartmouth College, and professor of community and family medicine, Dartmouth Medical School

Posted by Elizabeth Cooney at 11:44 AM

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Wednesday, October 3, 2007

New anesthesia method blocks pain without numbness or paralysis

By Colin Nickerson, Globe Staff

The world's hottest work in anesthesiology is being done at Harvard, where researchers are pouring pepper on pain.

Scientists at Harvard Medical School and Massachusetts General Hospital today described a new "targeted" approach to anesthesia that uses the active ingredient in chili peppers as part of an ingenious recipe for blocking pain neurons. Most critically, the technique doesn't cause the numbness or partial paralysis that is the unwelcome side effect of anesthesia used for surgery performed on conscious patients.

If approved for use in humans, the method could dramatically ease the trial of giving birth -- by sparing women pain while allowing them to physically participate in labor. It could also diminish the trauma of knee surgery, for instance, or the discomfort of getting one's molars drilled. Not only would there be no "ouch," there would be none of the sickening wooziness or loss of motor control that comes from standard forms of "local" anesthesia.

In time, the process might even be employed for major surgery on the heart and other organs, the researchers said. More prosaically, the work might also represent a breakthrough cure for the common itch.

The work on lab rats, described in the scientific journal Nature, breaks from the standard approach to local anesthesia, which usually involves anesthetics delivered by catheter tubes or injections that silence all neurons in a given region of the body, not just those that sense pain. Shutting down just the pain neurons means that patients could still feel a light touch and other non-hurtful sensations.

"This could really change the experience of, for example, knee surgery, tooth extractions, or childbirth," said Dr. Clifford Woolf, senior author of the study and a researcher in anesthesia and pain management at Mass. General. "The possibilities are almost endless."

Woolf collaborated with Bruce Bean, professor of neurobiology at Harvard Medical School, in research that employed surprisingly basic scientific principles as well as some unlikely ingredients -- capsaicin, the stuff that imparts "hot" to chili peppers, as well as an all-but-forgotten variation of a standard anesthesia, long dismissed as clinically useless.

"We plucked a little of this and little of that off the shelves," Bean said. "The project is really a great illustration of how basic biological principles can have very practical applications."

Indeed, scientists with no involvement in the Harvard study were most surprised by its simplicity.

"It's a really clever piece of work, based on one of those 'I wish I'd thought of that' ideas," said Dr. Stephen G. Waxman, head of the department of neurology at Yale University's School of Medicine. "This is an important piece of research."

There's also sweet historic symmetry to the discovery.

Boston, after all, is the city that invented feeling no pain -- at least in surgery.

Modern anesthesia was first successfully employed in surgery in October 1846, one of the greatest moments in medicine. In Boston's Public Garden, the second-largest statue -- after that of George Washington on his horse -- is a soaring pillar, adorned with roaring lions and bas-relief depictions of 19th Century surgeons, that celebrates the "discovery that the inhaling of ether causes insensibility to pain. First proved to the world at the Massachusetts General Hospital."

Not far away, modern Mass. General's original "ether dome" still stands, a national landmark and popular pilgrimage point for anesthesiologists from around the world.

The work undertaken by Woolf, Bean and post-doctoral researcher Alexander Binshtok exploits well-known concepts of how electrical signals in the nervous system depend on ion channels -- proteins that make passageways through the membranes of nerve cells. Pain-sensing neurons possess a unique channel protein, TRPV1, but one that is usually blocked by a molecular "gate."

Medicine for more than 150 years has relied on general and standard anesthetics that penetrate and suppress sensation in all neurons, not just those nerve cells dedicated to sensing pain. That's why an epidural or a simple shot of Novocain leaves a whole region of the body numb or paralyzed, because all nerves cells are affected.

Enter the hot chili pepper, in the form of capsaicin.

Enter, too, a failed derivative of the common anesthetic lidocaine, invented in the 1940s. The derivative, known as QX-314, was deemed useless because it couldn't penetrate cell membranes to block sensation. In non-pharmaceutical terms, that's a bit like having a power shovel that can't cut earth.

In experiments, the Harvard researchers found that the chili pepper ingredient generated heat that opened the gate to pain neurons, but had no similar effect on other nerve cells. Then, when they introduced the lidocaine derivative, it charged through the open channels to block pain in those neurons, but was still unable to enter other nerve cells, such as "motor" neurons that control coordination and mobility.

Thus, in rat experiments, there appeared to be a total shutdown of pain, with no apparent numbness or paralysis.

The rats received injections near nerves leading to their hind feet, and lost the ability to feel pain in their paws. But they continued to scamper about their cages normally and showed sensitivity to touch and other stimulation.

"We introduced a local anesthetic selectively into specific populations of neurons," said Bean. "Now we can block the activity of pain sensing neurons without disrupting other kinds of neurons that control movements or non-painful sensations."

Experimentation will likely move on to to sheep, then humans. One problem that needs to be addressed is whether the capsaicin might cause such a burning sensation when first injected -- before the lidocaine derivitive shuts down the pain -- that it may be too uncomfortable for use as an anesthetic. But the researchers are confident they can find a more practical "warming" chemical to open the gateways to the pain neurons.

"This method could really transform surgical and post-surgical analgesia. Patients could remain alert without suffering pain. But they also wouldn't have to cope with numbness or paralysis," Woolf said.

Noting that itch-sensitive neurons are similar to nerves that sense pain, he added: "We may have even found a good treatment for the common itch."

Posted by Gideon Gil at 01:43 PM

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Friday, September 28, 2007

Emotional response: Journal readers write about dealing with a patient's death

Comments have flowed in from around the world in response to an essay in the New England Journal of Medicine about clinicians' emotions when they are faced with a patient's death. From Greater Boston have come notes on saying goodbye before death, staying engaged at the worst times, coping with suicide, crying and celebrating with patients, and turning the tables when the doctor's time comes.

Doctors, nurses, students and others offered their thoughts in an online forum on Dr. Katharine Treadway's
"The Code." She wrote that after a patient's death, she says aloud this phrase from a requiem mass: "May choirs of angels greet thee at thy coming."

Dr. Naomi Leeds of Massachusetts General Hospital commented that she wrote a letter to a patient dying of esophageal cancer to tell him how he had touched her life.

"I welcomed the opportunity for closure and was grateful that my colleague encouraged me to do this — I would not have thought to do this on my own," she wrote. "I think that we would all benefit by having more training on how to say goodbye and thank you to our patients who we know are going to die."

Dr. Robert Truog of Children's Hospital Boston said the essay gave him a chance to reflect on why he chose to specialize in pediatric intensive care medicine. Initially drawn to the challenge and excitement of making life and death decisions on a moment's notice, he has changed.

"In the long run, however, what has kept me most engaged in my specialty has been the opportunity to work with children and their parents through the worst times of their lives, helping them make decisions when none of the choices are good, and comforting them through the unimaginable depths of loss and sadness that accompany the death of a child," he wrote.

Death is "often uncommon and often traumatic for all involved" in child psychiatry, Dr. Steve Auster of Wellesley wrote. After a patient's suicide, clinicians met to talk about it and some of them attended the wake.

"Hard to imagine all that being possible in disciplines where death is more common, however that doesn't lessen the potential benefit of this processing," he wrote.

Stephanie Gill, a family nurse practitioner in Norwood, tries to put herself in the shoes of her patients.

"I've cried with them when it's bad news and celebrated with them when it's good news," she wrote. "I think the fact that we can make such a difference in someone's life (and in their death) is amazing."

And Dr. Thomas Amoroso of Quincy Medical Center said that spiritual rituals make him uncomfortable.

"To be honest, at my passing I want someone to make either a good joke, or best of all, a really bad pun," he wrote. "Honoring someone's life takes many forms, and I feel it is important to acknowledge that as well."

Posted by Elizabeth Cooney at 12:19 PM

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Wednesday, September 26, 2007

Journal asks: After a patient dies, how do doctors deal with their emotions?

It was more than 30 years ago, but Dr. Katharine Treadway (left) vividly remembers answering her first "code" call to revive a hospital patient.

The resuscitation attempt failed, and in this week’s New England Journal of Medicine she recalls what it felt like, as a freshly minted intern, to simply walk away from a life that had just ended.

“Someone had just died. But we all behaved as though that was not at all what had happened,” she writes. “We learned to bury our fear of death in an avalanche of knowledge. … And for good reason. We could not do what we do – take responsibility for the lives of our patients – if we were aware, minute to minute, of the true significance of what we were actually doing.”

The journal is publishing Treadway's essay to spark an online discussion, which the Boston-based publication calls Perspective Forum. Its physician readers are invited to write about how they cope with the emotions they put away while meeting clinical challenges.

Treadway, a Harvard Medical School faculty member and primary care doctor at Massachusetts General Hospital, writes that many doctors have private rituals they observe whenever a patient dies -- she says aloud, "May choirs of angels greet thee at they coming" -- but they rarely share them.

White Coat Notes asked Treadway what she would like to hear from readers, why she chose this topic, and what she teaches medical students about it.

What do you hope to hear in the forum?
What I hope is people will in fact share some of their experiences and write what it was like to be at a code the first time, or other experiences. I hope doing that is just the beginning of 'well, gee, if I write into the New England Journal, maybe I can talk to the doctor I share an office with.' I really believe that we’re all hungry for this.

What do you teach medical students about emotions?
I try to get them to recognize early how powerful they will become in the lives of their patients. I don't mean this in a hierarchical way. I mean when someone is ill, the emotional need that is there is so profound, if they don't recognize how powerful they are, they won't know how to use this in a positive fashion.

What about situations like the code call?
When you focus so intently on the problem you are trying to solve, (it’s) easy to forget about the person. I want them to remember to experience the experience and be aware of what’s taking place, not just the task.

There’s this tremendously fine line that we have to walk in terms of dealing with acute life-threatening situations in which you absolutely have to stifle your emotions. You can’t fling your hands into the air and say, 'Oh my god.' That wouldn’t help anyone.

At the same, time, if you completely shut that off, then you lose something.

How do you find that middle ground?
Part of the message I teach is being honest with yourself about what you have done well or not so well, and being aware of your emotions in a way that allows you to continue and come back another time.

How about your own work?
I love being a doctor. To me it's the combination of the intellectual demands and the fascination of how our bodies work, mixed with dealing with people and all of the interactions that take place in this human drama. I still feel like I have to pinch myself to believe I’m doing this, more than 30 years into it.

Being a primary care doctor, I take care of my patients’ children, or their children’s children, or in one case, the great-granddaughter of my original patient. In addition to teaching medical students who are so eager and idealistic, it’s just so renewing. I feel very lucky.

Posted by Elizabeth Cooney at 05:20 PM

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Mass. General scores on two workplace lists

Massachusetts General Hospital has landed on two lists of best places to work.

One is the Working Mother magazine's 100 Best Companies, which considers compensation, child-care and flexibility programs, and leave policies. Harvard University also made the non-ranked list, along with Arnold Worldwide, The Boston Consulting Group and Massachusetts Mutual Life Insurance.

The other list is AARP's ranking of Best Employers for Workers Over 50, where it came in 10th. No other Massachusetts-based company made the list of 50 workplaces. The AARP considered recruiting practices; opportunities for development; and work options, such as flexible scheduling, job sharing, and phased retirement, in addition to health and retiree benefits.

Posted by Elizabeth Cooney at 09:56 AM

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Monday, September 17, 2007

MGH names patient-care institute head

Gaurdia E. Banister (left) has been named the first executive director of The Institute for Patient Care at Massachusetts General Hospital, which includes centers for nursing research and professional development.

A registered nurse with a doctorate in psychiatric/mental health nursing, she had been senior vice president for patient care services at Providence Hospital in Washington, D.C., part of the Ascension Health System.

Posted by Elizabeth Cooney at 11:16 AM

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Thursday, August 16, 2007

New physician-scientists win Howard Hughes awards

Seven Boston physicians who spent a year or more away from medical school doing research have won grants to continue their dual roles as scientists and clinicians.

The Howard Hughes Medical Institute has given Early Career Awards of $375,000 each over five years to 20 doctors to make sure they have the time and financial support for research early in their careers, it said in a statement. Their institutions agreed to allow these tenure-track physician-scientists to devote at least 70 percent of their time to research.

The winners are alumni of either HHMI's research scholars or training fellowship programs, which bring students to the National Institutes of Health or other institutions. They are:

Dr. Sarah Fortune, Harvard University School of Public Health
Dr. Aram Hezel, Massachusetts General Hospital
Dr. Farouc Jaffer, Massachusetts General Hospital
Dr. Eric Johannsen, Brigham and Women's Hospital
Dr. Sridhar Ramaswamy, Massachusetts General Hospital Cancer Center
Dr. Manish Sagar, Brigham and Women's Hospital
Dr. Sean Savitz, Beth Israel Deaconess Medical Center

Posted by Elizabeth Cooney at 01:49 PM

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Friday, August 3, 2007

MGH research center to focus on heart arrhythmia and stroke

Massachusetts General Hospital has created The MGH Deane Institute for Integrative Research in Atrial Fibrillation and Stroke, the hospital said today.

Funded by a $10 million gift from MGH donors Disque and Carol Deane, the center will combine efforts of the cardiac arrhythmia service led by Dr. Jeremy Ruskin and the stroke service headed by Dr. Karen Furie to improve prevention and treatment of strokes related to atrial fibrillation.

Posted by Elizabeth Cooney at 05:08 PM

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Tuesday, July 24, 2007

Mass. General surgeons win suit brought by Notre Dame coach

A jury today found in favor of two Massachusetts General Hospital surgeons who had been sued for malpractice by University of Notre Dame football coach Charlie Weis, who bled internally after gastric bypass surgery five years ago.

The Suffolk Superior Court jury found that surgeons Charles Ferguson and Richard Hodin were not negligent in their care of Weis, former offensive coordinator of the New England Patriots who nearly died after the 2002 obesity surgery and testified that he still has difficulty walking.

Internal bleeding is a known complication of gastric bypass surgery, and the doctors argued that they waited to perform a second operation to stop the bleeding because they thought it would stop on its own and were concerned about risks of further surgery.

The first trial of the malpractice suit ended dramatically in a mistrial in February, after the surgeons rushed to the aid of a juror who had collapsed in the courtroom.

Posted by Gideon Gil at 03:26 PM

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Wednesday, July 18, 2007

NEJM: Leaving against medical advice

In tomorrow's New England Journal of Medicine, a first-year internal medicine resident at Massachusetts General Hospital, writes an eye-opening essay about his experience treating a critically ill patient who, against medical advice, decided to leave the hospital.

The patient, a 29-year-old heroin addict who spoke only Spanish, was hospitalized with a heart infection and failing heart, among other problems.

"We tried deals and scare tactics, telling him as clearly as we could that he was more likely to die if he left this way," writes Dr. Viviany R. Taqueti. "When he countered with 'that is up to God,' we offered him consultation with a priest. An interventionalist, overhearing this exchange, called us warm and fuzzy. Our efforts felt futile, and we were weary. Yet it seemed wrong not to keep trying."

Later, Taqueti writes, "I listened to his heart one more time ... I heard those ominous rumbles and screeches, and they startled me with their threat of impending death, obvious even to me. But (the patient) could not hear them, and I wondered how much of his failure to hear was due to our failure to translate.

"I placed the stethoscope in his ears. (The patient) raised his eyebrows in astonishment but said nothing. I knew this simple hearing aid could not remedy his deafness, arising as it did from barriers of language, culture, denial, distrust, and drug dependency. I was left frustrated, sad, and tired."

Posted by Gideon Gil at 08:04 PM

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Friday, July 13, 2007

On the blogs: Levy ponders surgeons' report card Catch-22

Public reporting campaign meets surgical caution on Running a Hospital today.

In this week's New England Journal of Medicine three Harvard doctors argue that making mortality rates public for individual cardiac surgeons could end up harming patients if the rankings push surgeons to avoid operating on high-risk patients.

Today Paul Levy responds in detail to the White Coat Notes post about the opinion piece in the journal, written by Dr. Thomas H. Lee of Partners Health Care, Dr. David F. Torchiana of Massachusetts General Hospital and Dr. James E. Lock of Children’s Hospital Boston.

As readers of the Beth Israel Deaconess CEO's blog know, Levy is a champion of transparency, urging other hospitals to join his in posting their performance measures. He responds to the doctors' contention that public reporting is too flawed (not adequately adjusted for risk, too small a sample) to be valid. (He also asks many questions -- it's a long entry.)

"So here's our Catch-22: No reporting method is statistically good enough to be made public," he writes. "But if a method is statistically good enough, we won't allow it to be made public."

Then Levy issues a challenge to health care providers:

"The medical profession simply has to get better at this issue. If they don't trust the public to understand these numbers, how about just giving them to referring primary care doctors? Certainly, they can trust their colleagues in medicine to have enough judgment to use them wisely and correctly."

And another to insurers:

"We hear a lot about insurance companies wanting to support higher quality care. When is an insurance company going to demand that the hospitals in its network provide these data to referring doctors in its network? How about this for an idea? If a hospital doesn't choose to provide the data, it can still stay in the network, but the patient's co-pay would be increased by a factor of ten if he or she chooses that hospital."

Posted by Elizabeth Cooney at 04:46 PM

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MGH, Brigham make US News honor roll

Massachusetts General Hospital and Brigham and Women's Hospital held on to their honor roll positions in the annual rankings by U.S. News & World Report called "America's Best Hospitals." Nine Boston hospitals are featured in the guide.

Mass. General finished fifth in the standings, down one rung from last year, and the Brigham took tenth place, up one from last year. Once again, Johns Hopkins Hospital and the Mayo Clinic finished first and second. UCLA Medical Center moved up to third from fifth and the Cleveland Clinic slipped to fourth from third.

The magazine evaluated 5,462 hospitals in 16 specialties, excluding pediatrics, and came up with 173 hospitals that met standards in one or more specialties based on reputation, care-related factors such as nursing and patient services, and mortality rate. Eighteen hospitals scored at or near the top in at least six specialties to make the honor roll.

Other hospitals were ranked i